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A03276 Summary:

A03276 Actions:

A03276 Committee Votes:

Committee:INSURANCE   Chair:Cahill      
DATE:01/20/2022AYE/NAY:23/2  Action: Favorable         
Cahill
Aye
Blankenbush
Aye
Cook
Aye
Hawley
Nay
Pretlow
Aye
Byrne
Aye
Rivera
Aye
Schmitt
Aye
Cymbrowitz
Aye
Palmesano
Aye
Lavine
Aye
DiPietro
Nay
Steck
Aye
Gandolfo
Aye
Dilan
Aye
Hunter
Aye
Niou
Aye
Rosenthal
Aye
Stern
Aye
McDonald
Aye
Jacobson
Aye
Williams
Aye
Meeks
Aye
Forrest
Aye
Anderson
Aye

A03276 Floor Votes:

A03276 Text:

 
                STATE OF NEW YORK
        ________________________________________________________________________
 
                                          3276
 
                               2021-2022 Regular Sessions
 
                   IN ASSEMBLY
 
                                    January 22, 2021
                                       ___________
 
        Introduced  by M. of A. GUNTHER -- read once and referred to the Commit-
          tee on Insurance
 
        AN ACT to amend the insurance law, in relation to prohibiting the appli-
          cation of fail-first or step therapy protocols  to  coverage  for  the
          diagnosis and treatment of mental health conditions

          The  People of the State of New York, represented in Senate and Assem-
        bly, do enact as follows:
 
     1    Section  1.  Subparagraphs  (A),  (C)  and  (E)  of  paragraph  35  of
     2  subsection (i) of section 3216 of the insurance law, as added by section
     3  8 of subpart A of part BB of chapter 57 of the laws of 2019, are amended
     4  to read as follows:
     5    (A)  Every  policy delivered or issued for delivery in this state that
     6  provides coverage for inpatient hospital care or coverage for  physician
     7  services  shall  provide  coverage  for  the  diagnosis and treatment of
     8  mental health conditions as follows:
     9    (i) where the policy provides coverage for  inpatient  hospital  care,
    10  benefits  for inpatient care in a hospital as defined by subdivision ten
    11  of section 1.03 of the mental hygiene law and  benefits  for  outpatient
    12  care  provided  in  a  facility  issued  an operating certificate by the
    13  commissioner of mental health pursuant  to  the  provisions  of  article
    14  thirty-one  of  the mental hygiene law, or in a facility operated by the
    15  office of mental health, or, for care provided in other states, to simi-
    16  larly licensed or certified hospitals or facilities; and
    17    (ii) where the policy provides coverage for physician services,  bene-
    18  fits  for  outpatient  care  provided  by a psychiatrist or psychologist
    19  licensed to practice in this state, a licensed  clinical  social  worker
    20  who  meets  the  requirements  of  subparagraph (D) of paragraph four of
    21  subsection (1) of section three thousand two hundred twenty-one of  this
    22  article,  a  nurse practitioner licensed to practice in this state, or a
    23  professional corporation  or  university  faculty  practice  corporation
    24  thereof, including outpatient drug coverage.
 
         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.
                                                                   LBD02946-01-1
        A. 3276                             2
 
     1    (C)  Coverage  under this paragraph shall not apply financial require-
     2  ments or treatment limitations to mental health benefits, including drug
     3  coverage, that are  more  restrictive  than  the  predominant  financial
     4  requirements  and  treatment  limitations  applied  to substantially all
     5  medical and surgical benefits covered by the policy. Coverage under this
     6  paragraph,  including  drug  coverage, shall not apply any fail-first or
     7  step therapy protocol, as defined by section four thousand nine  hundred
     8  of this chapter.
     9    (E) For purposes of this paragraph:
    10    (i)  "financial requirement" means deductible, copayments, coinsurance
    11  and out-of-pocket expenses;
    12    (ii) "predominant" means that a  financial  requirement  or  treatment
    13  limitation  is  the  most  common  or  frequent of such type of limit or
    14  requirement;
    15    (iii) "treatment limitation" means limits on the frequency  of  treat-
    16  ment, number of visits, days of coverage, or other similar limits on the
    17  scope  or  duration  of treatment and includes nonquantitative treatment
    18  limitations such as: medical management standards limiting or  excluding
    19  benefits  based  on medical necessity, or based on whether the treatment
    20  is experimental or investigational; formulary  design  for  prescription
    21  drugs;  network tier design; standards for provider admission to partic-
    22  ipate in a network, including reimbursement rates; methods for determin-
    23  ing usual, customary, and reasonable charges; [fail-first or step thera-
    24  py protocols;] exclusions based on  failure  to  complete  a  course  of
    25  treatment; and restrictions based on geographic location, facility type,
    26  provider  specialty, and other criteria that limit the scope or duration
    27  of benefits for services provided under the policy; and
    28    (iv) "mental health condition" means any  mental  health  disorder  as
    29  defined  in  the  most  recent edition of the diagnostic and statistical
    30  manual of mental disorders or the most recent edition of another  gener-
    31  ally recognized independent standard of current medical practice such as
    32  the international classification of diseases.
    33    §  2.  Subparagraphs (A), (C) and (E) of paragraph 5 of subsection (l)
    34  of section 3221 of the insurance law, subparagraph  (A)  as  amended  by
    35  section 13 of subpart A of part BB of chapter 57 of the laws of 2019 and
    36  subparagraphs (C) and (E) as added by section 14 of subpart A of part BB
    37  of chapter 57 of the laws of 2019, are amended to read as follows:
    38    (A) Every insurer delivering a group or school blanket policy or issu-
    39  ing  a group or school blanket policy for delivery, in this state, which
    40  provides coverage for inpatient hospital care or coverage for  physician
    41  services  shall  provide  coverage  for  the  diagnosis and treatment of
    42  mental health conditions and:
    43    (i) where the policy provides coverage for  inpatient  hospital  care,
    44  benefits  for inpatient care in a hospital as defined by subdivision ten
    45  of section 1.03 of the mental hygiene law and  benefits  for  outpatient
    46  care  provided  in  a  facility  issued  an operating certificate by the
    47  commissioner of mental health pursuant  to  the  provisions  of  article
    48  thirty-one  of  the mental hygiene law, or in a facility operated by the
    49  office of mental health or, for care provided in other states, to  simi-
    50  larly licensed or certified hospitals or facilities; and
    51    (ii)  where  the  policy  provides coverage for physician services, it
    52  shall include benefits for outpatient care provided by a psychiatrist or
    53  psychologist licensed to practice in this  state,  a  licensed  clinical
    54  social  worker  who  meets the requirements of subparagraph (D) of para-
    55  graph four of this subsection, a nurse practitioner licensed to practice
        A. 3276                             3

     1  in this state, or a professional corporation or university faculty prac-
     2  tice corporation thereof, including outpatient drug coverage.
     3    (C)  Coverage  under this paragraph shall not apply financial require-
     4  ments or treatment limitations to mental health benefits, including drug
     5  coverage, that are  more  restrictive  than  the  predominant  financial
     6  requirements  and  treatment  limitations  applied  to substantially all
     7  medical and surgical benefits covered by the policy. Coverage under this
     8  paragraph, including drug coverage, shall not apply  any  fail-first  or
     9  step  therapy protocol, as defined by section four thousand nine hundred
    10  of this chapter.
    11    (E) For purposes of this paragraph:
    12    (i) "financial requirement" means deductible, copayments,  coinsurance
    13  and out-of-pocket expenses;
    14    (ii)  "predominant"  means  that  a financial requirement or treatment
    15  limitation is the most common or frequent  of  such  type  of  limit  or
    16  requirement;
    17    (iii)  "treatment  limitation" means limits on the frequency of treat-
    18  ment, number of visits, days of coverage, or other similar limits on the
    19  scope or duration of treatment and  includes  nonquantitative  treatment
    20  limitations  such as: medical management standards limiting or excluding
    21  benefits based on medical necessity, or based on whether  the  treatment
    22  is  experimental  or  investigational; formulary design for prescription
    23  drugs; network tier design; standards for provider admission to  partic-
    24  ipate in a network, including reimbursement rates; methods for determin-
    25  ing usual, customary, and reasonable charges; [fail-first or step thera-
    26  py  protocols;]  exclusions  based  on  failure  to complete a course of
    27  treatment; and restrictions based on geographic location, facility type,
    28  provider specialty, and other criteria that limit the scope or  duration
    29  of benefits for services provided under the policy; and
    30    (iv)  "mental  health  condition"  means any mental health disorder as
    31  defined in the most recent edition of  the  diagnostic  and  statistical
    32  manual  of mental disorders or the most recent edition of another gener-
    33  ally recognized independent standard of current medical practice such as
    34  the international classification of diseases.
    35    § 3. Paragraphs 2 and 4,  and  subparagraph  (C)  of  paragraph  6  of
    36  subsection  (g)  of  section  4303  of the insurance law, paragraph 2 as
    37  added by section 22 of subpart A of part BB of chapter 57 of the laws of
    38  2019, and paragraph 4 and subparagraph (C) of paragraph 6  as  added  by
    39  section  23  of  subpart A of part BB of chapter 57 of the laws of 2019,
    40  are amended the read as follows:
    41    (2) where the contract provides coverage for physician services  bene-
    42  fits  for  outpatient  care  provided  by a psychiatrist or psychologist
    43  licensed to practice in this state, a licensed  clinical  social  worker
    44  who  meets  the  requirements of subsection (n) of this section, a nurse
    45  practitioner licensed to practice on this state, or professional  corpo-
    46  ration  or  university  faculty  practice corporation thereof, including
    47  outpatient drug coverage.
    48    (4) Coverage under this subsection shall not apply financial  require-
    49  ments or treatment limitations to mental health benefits, including drug
    50  coverage,  that  are  more  restrictive  than  the predominant financial
    51  requirements and treatment  limitations  applied  to  substantially  all
    52  medical  and  surgical benefits covered by the contract.  Coverage under
    53  this paragraph, including drug coverage, shall not apply any  fail-first
    54  or  step  therapy  protocol,  as  defined  by section four thousand nine
    55  hundred of this chapter.
        A. 3276                             4
 
     1    (C) "treatment limitation" means limits on the frequency of treatment,
     2  number of visits, days of coverage, or other similar limits on the scope
     3  or duration of treatment and includes nonquantitative treatment  limita-
     4  tions  such as: medical management standards limiting or excluding bene-
     5  fits  based  on  medical necessity, or based on whether the treatment is
     6  experimental  or  investigational;  formulary  design  for  prescription
     7  drugs;  network tier design; standards for provider admission to partic-
     8  ipate in a network, including reimbursement rates; methods for determin-
     9  ing usual, customary, and reasonable charges; [fail-first or step thera-
    10  py protocols;] exclusions based on  failure  to  complete  a  course  of
    11  treatment; and restrictions based on geographic location, facility type,
    12  provider  specialty, and other criteria that limit the scope or duration
    13  of benefits for services provided under the contract; and
    14    § 4. This act shall take effect immediately and  shall  apply  to  all
    15  policies  and contracts issued, renewed, modified, altered or amended on
    16  or after such date.